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��II'�I �I'' � � <br />� <br />Finance Department, License Divisian <br />26b0 Civic Cenfer �rive, RosevilIe, MN 55113 <br />(b51) 792-7Q36 <br />11�assage 'I'herapis� License <br />New Licanse Renewai r " <br />For License year <br />1. L,egai Name <br />g 3une 30 �U� <br />� � <br />�' .� o se L a�[ i�'Ul G I/� <br />— .� . �F � r <br />2, Home Address_ � � <br />3. Home TelephoneT _ <br />4. Date of Birth .� <br />— -- 1 <br />� A _ <br />5. Drivers License Nrunber <br />- . .� <br />6. Emafl Address �� . �-r�. ._,.,, _ _ „ <br />7. Have you ever useci or been icnown by any name other than the ]egal name given in number I above? <br />Yes _ No _ � If yes, list each name alang wiih dates and places where used. <br />���� }[[ 8. Name a.nd dre s of the icensed Massag Therapy Esta lishment. that you ex ct to be employed by. <br />,�.�,e VwCk �' e,� � � 0 fa au <br />e`�1°Y � Posev��Le �?�1 S ff 3 <br />9. Attach a certi#ied copy of a diploma or certifcate of gra�uation from a schoal of massage therapy <br />including a rr►inimum of 600 hours in successfi�lly completed ur e work as described in Roseville <br />Ordinance ] 16, rriassage Therapy Establistunents. D� �` � <br />f �° <br />l0. Have you had any pre�ious massage therapist license that was revoked, suspended, or not renewed? <br />Yes No ]� if yes exPlain in detai�. <br />�,icense fee is 75.00 <br />Make chec[�s payable to City of Roseville <br />� <br />